Contents -

Form 5498-SA

Form 5498-SA - HSA, Archer MSA or Medicare Advantage MSA Information

File Form 5498-SA with the IRS on or before May 31, 2007, for each person for whom you maintained an HSA, Archer MSA or Medicare Advantage MSA (MA MSA) during 2006.  You are required to file if you are the trustee or custodian of an HSA, Archer MSA or MA MSA.  A separate form is required for each type of plan.

For HSA or Archer MSA contributions made between January 1 and April 16, 2007, you should obtain the participant's designation of the year for which the contributions are made.

Account number (Required)
Enter any number assigned by the payer to the payee that can be used by the IRS to distinguish between information returns.  This number must be unique for each information return.  The account number is critical in the correction process, especially when more than one information return is filed for a payee.  MAG-FILER will automatically assign an account number if the field is blank.

TIN # (Required)
Enter the payee's valid 9-digit Taxpayer Identification Number (SSN or EIN, as appropriate).  Leave this field blank if the TIN# is unknown.   Any form filed containing an invalid identification number in this entry may be returned for correction.

SSN  (else EIN) (Required)
Check this box if the payee TIN # is a Social Security Number (SSN) of an individual.  Leave this box blank if the payee TIN # is an Employer Identification Number (EIN) of a business or an organization.

NOTE: Imbedded blanks, extraneous words, titles, and special characters ( i.e., Mr., Mrs., Dr., period [.], apostrophe [ ' ] should be removed from Payee Name Lines.  An ampersand (&) and a dash (- ) are the only acceptable special characters.  A comma ( , ) between last name and first name that is placed by MAG-FILER is also acceptable.

Name (Required)
Enter the name of the recipient belonging to the Taxpayer Identification Number (TIN).  If the TIN, is an SSN, enter as last name suffix, first, middle initial, e.g., Doe Jr., John A.).  If the TIN is an EIN, the name is entered as is.  Use the Second Name Field if additional space is required.

Second Name Field
If the payee name requires more space than is available in the name field, ENTER ONLY THE REMAINING PORTION OF THE NAME IN THIS ENTRY.  If there are multiple payees, this field may be used for those payees' names.  DO NOT USE THIS FIELD FOR ADDRESS INFORMATION. 

Address (Required)
Enter the payee's mailing address.  The address MUST be present.  This entry must not contain any data other than the payee's mailing address.

City (Required)
Enter the payee's city.   Do not enter state and zip code information in this entry.

State (Required)
Enter the abbreviation for the payee's state or foreign country.  You must use valid U.S. Postal Service state abbreviations for U.S. addresses.

Zip (Required)
Enter the payee's valid 9-digit zip code assigned by the U.S. Postal Service.

Employee/Self-empl Archer MSA Contrib. Made in 2007/2008 for 2007: 
Enter the employee's or self-employed person's regular contributions to the Archer MSA made in 2007 and through April 16, 2008, for 2007.  Report gross contributions, including any excess contributions, even if the excess contributions were withdrawn.  No HSA information is to be reported in this field.
 
Total Contributions Made in 2007: 
The total HSA or Archer MSA contributions made in 2007.  Include any contribution made in 2007 for 2006.  You may, but you are not required to, report the total MA MSA contributions the Secretary of Health and Human Services or his or her representative made in 2007.

Total HSA or Archer MSA Contributions Made in 2008 for 2007:
The total Archer MSA contributions made in 2008 for 2007.

Rollover Contributions:
The rollover contribution made to the HSA or Archer MSA received by you during 2007.

Fair Market Value of HSA, Archer MSA or MA MSA: 
The fair market value of the account on December 31, 2007.
 
HSA:
Check this box if this account is HSA.

Archer MSA:
Check this box if this account is Archer MSA.

MA MSA:
Check this box if this account is Medicare Advantage MSA.

Special
This area may be used to record information for state or local government reporting or for the filer's own purposes.  This information will be sent to the IRS file and does not print to the form.

Select Print
Check this box to select specific payees for printing.

Corrected Return
Check this box if this entry is a corrected return.  This is only used IF YOU HAVE ALREADY SUBMITTED MAGNETIC MEDIA FILING and wish to print or file corrected returns.  NOTE: The same account number reported on the original must also be on the corrected record.